A Day with Nurse Sue....

Learning about new products has always been a lot of fun for me, and whenever possible I like to go to the company and experience their product and meet their team in person. Just to be clear I am not a journalist, and everything I blog is my opinion. So, this is the story about my day with Nurse Sue.

As I entered the doors of Capsule Tech I was greeted by a friendly a woman and welcome sign displaying my name and company logo. In the corner was a larger than life cardboard cutout of the Nurse Sue Avatar, and down the hall came the real Susan Niemeier. She is an adorable red head with a bright midwest smile and matched warmth. There was no formality just a friendly hello and then off to get some coffee in the break room.

Our first order of business was a tour of the office. It’s not flashy – but nice – a large space with cubicles and a few conference rooms. Nurse Sue pointed out the large black and white pictures on the walls were their colleagues in Paris, and in Paris they have pictures of their colleagues in the US. Every person seemed busy but happy and frankly excited to be working on challenging projects. A few had Avatars which made me write *add S3 K Avatar to the development list. I internally sighed with relief. I have grown weary of the corporate stodginess and the competitiveness of HIT.

As we settled into the conference room, Nurse Sue delved into her passion for clinicians and how to drive more time at the Point of Care. She bubbled about the product she manages and how she believed it would – make life better. We dove in and vividly she relayed the story of “her” MVP. The Mobile Vitals Plus is really a simple product. It’s a box (isn’t everything ) that takes the vitals collected by almost any mobile vitals device (demonstrated with the GE device) – it automatically collects the data, allows the clinician to confirm, compiles it in a server, and then sends it to the medical record…any medical record.

MVP was created for Nurses by Nurses with influences from – not technologists – but Human Factors Engineers. The device is ergonomically designed to have the most beneficial colors for reduced eye strain to the most beneficial placement for the log on/off button. I was very pleased with the company’s commitment to not just make a product but make one that was easy to use. The presentation ebbed and flowed in and out of conversations of industry, family, business, and baseball (we were in Boston). I ended the day thinking – wow, these are good people trying to make a difference.

It is clear that Capsule is a darling in the industry. But Why?

• It could be their Switzerland Status. They closely align with many EMR companies, but are married to none.
• It could be their well thought out – well researched product. Nurse Sue’s commitment to research to make sure the product truly makes a difference is fed from her history of research on projects such as the Kaiser/ Ascension Time Motion Study and the ever famous Proclamation for Change. This woman gets data like few I have met.
• It could be their people – many who I have termed “the good guys”
• It could be a methodically planned approached to product, implementation, and test…continuously improve. Wash – Rinse – Repeat.
• It could be their culture. Friendliness, Transparency, and a non-smearing attitude. They don’t spread FUD (my favorite new term from @VoalteTrey) Fear Uncertainty and Doubt – they just are who they are.
• It could be that they are small and in small companies ideals and vision are easily disseminated amongst the team. There is no clawing to the top – you just walk down the hall way.

 It “could” be anything – end of the day this will make life better. 

This is my quest - if you have Healthcare IT products that "Make Life Better" I want to know about them.  I am interested in learning and sharing.   If you are a hospital with a process that will "Make Life Better" for other clinicians using HIT - I am intersted in learning and sharing.  

Today.....

If we are honest with ourselves there are times in our career where we grapple with the business verse human aspects of our products. We seek balance. We balance making money with helping people. We balance “marketing messages” and big picture vision with everyday life in the weeds. We balance heart and commitment to being the change with the work that must be done.

On the 3 year anniversary of Sphere3, I find myself evaluating the balance of building a start up and staying true to my commitment to Make Life Better for Patients AND Caregivers. Today – I focus on the Caregiver.


There were two blogs that caught my attention over the past few weeks. One blog was noted by Paul Levy called “Medical Margins” by Josephine Ensign. Josephine tells the story of a RN who had made a medical error – her blog blasts the hospital for the inequality of discipline levels between Docs and Nurses. Really what struck me was Kimberly Hiatt – a veteran RN with all in all good approval ratings – was dismissed for her error of administering a lethal dose of medication to a fragile NICU baby. After which she committed suicide. (Note there is no public information about linking her suicide to her dismissal)

I struggle with the balance – a bad day for me is I publish something on the blog that irritates someone or my team misses an internal development deadline.  (which is really a bad day for them) A bad day for a RN is someone could be seriously harmed or die. Do we expect perfection? Are we being realistic to apply “lean six sigma” principles to a human based profession – patients are not cars and clinicians are not assembly line workers. The patient advocate side of me really wants to drive every ounce of error out of existence. What if that error was my child – what if that “bad day” affected my parent? Aperum™ was created to identify when workload balances are too great. Is it enough? Do we find that self reporting based EMR systems and other gadgets and gizmos really make a difference in the day of the RN?

When my brain went into over drive trying to grapple with it all another great blog was posted – this time by a Nursing Student named Jennifer-Clare Williams of my home state Missouri. Her heartfelt desire to be the super hero that “saves the world one patient at a time” brings back the sovereignty of unadulterated hope. The blog is beautiful – showing her true desire to be a help to those in need.

I replay my mistakes (“No wonder your patient was uncomfortable—you put the bedpan under her backwards!”), I cry more than I ever have in my life, and I continuously wonder how on earth I will ever learn everything I need to know.

But there is good news. I’m surviving. And I’m learning that perfection is unrealistic. That nursing really is a fluid profession: things are constantly changing, and that’s a good thing. That there are very few things that I’m going to master on the first try, or heck, even the 10th try . . . but that’s ok. I’m learning that the patients who are, let’s just say . . . unkind . . . are not launching a personal attack on me, but are facing a difficult set of circumstances and are unhappy with the situation.

The inspirational heart of this young woman pushes me forward that every nugget of information we can provide back in a visual meaningful way can make a difference to improve her ability to provide care. The S3 team has made linkages to reduce readmissions, show documented improvement to patient satisfaction scores, reduce fall rates and errors, and do all the big picture money saving things that we need to do to sell a product. That’s not what drives me – and technologist – EMR person – industry specialist – big picture lingo laden with catch phrases shouldn’t be what drives you either.

What drives me should be the thought that today – we made life better for Jennifer because we were able to identify that her workload was so great that she may make an unintended mistake. What drives me should be that today we were able to provide information to the charge nurse that over stimulation was increasing the propensity for medication error beyond capacity – so she can engage and make sure her clinicians are in an environment where they can care and not run. What is your “today” statement? What did your product, software, service do today to Make Life Better?

For a moment, stop and focus on how you can make life better. Stop thinking about selling the next big deal and start thinking about the people you are affecting.

Thanks to:

Josephine Ensign’s “Medical Margins” Blog
http://josephineensign.wordpress.com/2011/04/24/to-err-is-human-medical-errors-and-the-consequences-for-nurses/#comments

Off the Charts AJN Notes of a Student Nurse: A Dose of Reality written by Jennifer-Clare Williams http://ajnoffthecharts.com/2011/05/04/notes-of-a-student-nurse-a-dose-of-reality/

Everytime......

It’s funny when people know what you do how the conversation trends towards that topic. One of my dear friends mother has been in the hospital for over a month with kidney failure and infection. Tammy has been the epitome of advocacy. She called me one afternoon to share the trials she was going through.  Pouring her heart out to release the pain of watching her mother suffer.  Before she got off the phone she said “Make sure to tell your friend – the boss here – how great our experience has been – how great these nurses are in making sure we are taken care of every time we need something.” My friend, Damond Boatwright, the CEO of Lee’s Summit Medical Center has done a great job of cultivating a culture of caring staff.

I began to think about that statement “making sure we are taken care of every time we need something.” I know that hospital – I know the technology, the staff, the design, the process, and how they manage their care. Managing by metrics is only part of the equation – the other half is care.

I had a great post written for you all – about metrics and managing by numbers and pushing for results. It was insightful and interesting with recent data from a new hospital.  Exploring Dynamic vs Intuitive responses based on the “need type” and weighting averages. Numbers and the quantification of expectations – it was brilliant……..but listening to Tammy reminds me - it's only part of the solution....have you been reminded today?  If you haven't had a recent hospital encounter - technologist, you need one.  Don't let the math cloud the reality of what we all do.  Don't let the flashy exciting technology be the cetner of your universe.  Don't let competition between bitter rivals reduce the ability for the patient to have the win.  I want to win as bad as the next guy - but I don't want to win at the expense of the patient.

Maybe some of the best things I post have nothing to do with fancy math (or as Steve says "Algorithms")  but have everything to do with the human condition – the patient as a person – the clinician as a giver.

Who would think a geek could feel?

Press Release on APERUM

Kansas City, Missouri (April 18, 2011) -- Sphere3™ Releases Aperum™ targeting patient satisfaction Indicares™ within U.S. Hospitals. Sphere3™ is the first to reach the market in an emerging category of software targeting patient satisfaction and safety during a hospital stay. Since it’s inception in 2009, Sphere3™ has focused on nursing activities that indicate quality of care. Aperum™ uses data found within standard transactions of the hospital’s patient communication platform to provide performance and risk indications.




The Company’s proprietary algorithms dissect the data path and normalize basic elements for analysis related to patient requests and resulting caregiver responses. The resulting Indicares™ within Aperum™ reveal actual caregiver performance against hospital expectations for performance based on patient needs by category. Further analysis within Aperum™ reveals behavioral patterns for patients and peak times for certain patient needs, offering new insights in caregiving and staffing models.



“We are very excited about how Aperum™ can advance the suite of clinical management tools within the hospital,” says Kourtney Govro, Founder and CEO of Sphere3™. “Most CNOs and Directors of Nursing manage staffing and clinical care decisions based on subjective data. Few have access to the necessary technical expertise to evaluate the real and changing patterns of patient needs and caregiver response.”



Hospitals invest heavily in the nurse call systems and clinical alarms found in a patient’s room. These devices are the primary method in which patients can request assistance from hospital staff. In some cases, the systems have advanced to “sense” patient needs based on physiological movement or biometrics and automatically generate a request from the room. Although very technical and advanced in their design, the platform makers are more about devices and less about offering critical management information. Yet, the systems are rich in data and capable of revealing behavioral patterns in patient care.



Govro offers, “Our progress was initially challenged by the lack of understanding for the information available from resident systems. We are bridging the knowledge gap within the hospital by creating a common language for this data and the behavioral patterns revealed within it.”



Govro believes a number of drivers will aggressively move hospitals to using this new category of software. For example, Lean Principles for staffing target more flexible movement of staff as needed throughout the hospital without compromising the level and quality of care. Objective measures of patient needs, priority, wait times and associated risks should assist caregivers and managers in assigning the right staff at the right time to a floor.



“Patient safety is at the heart of this balance,” Govro says. “Patients are in the hospital because of acute needs. The simple act of getting out of a bed unsupervised creates the risk of a fall, which is a costly event for hospitals.”



Govro explains patient falls are closely measured by hospitals. Because the event is considered avoidable, Medicare and insurance companies deny the associated costs of care linked to the fall, including additional days of stay in the hospital. According to a study completed by the Washington University School of Medicine, St. Louis, MO with Barnes Jewish Hospital, St. Louis, MO in 2004, the typical patient fall occurred during activities unassisted by staff (79%) in the patient room (85%)1.



The makers of patient communication platforms place continue to investment heavily in more accurately categorizing and routing the patient needs to caregivers. Sphere3™ has filled the information void by developing the necessary enterprise level management software to manage the aggregate of needs with caregiver availability.



“Although Version 1.0 is a retrospective review of the data,” Govro says, “future versions will move data to real-time and allow for immediate care management decisions.”



1 Characteristics and Circumstances of Falls in a Hospital Setting: A Prospective Analysis. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1492485/)

How to Define "Help"?

When you order BBQ in Kansas City – you don’t just order burnt ends – you can order chopped burnt end sandwiches which can be sauced or dry – you can order a platter which can be sauced or dry – you can order it as a combo. Then there are the side dish selections…cheesy corn, beans, slaw, pickles….

Question #4 “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”

The interesting thing about the next section of the question is its tie to “help”.   What defines help?  In most hospitals if you press the “call button” there is one “button” it’s big and it’s red. You can figure out it’s for “help” even when you are groggy or sick. The newest fad is to add more buttons – which is great for me would work. I am used to self selecting. I self-check at the airport, I order meals and movies on my Iphone, and think nothing of the lack of real “service” that is providing.

My mom (who is 62) would think the extra buttons were a novelty. She would laugh as she tried to find her glasses to read the small words on the extra buttons “water, pain, or toilet” then ask me if she pressed toilet does that mean she has to go or that she went. She would never press the pain button because she rarely admits when she is in pain.  She would always press the red button.  (Please no hate mail here, I am generalized a generation based on my experience with my parents)

My grandma would press no buttons….even with her glasses she probably couldn’t read those little words, and she would look at the crazy “paddle” and say why are there so many buttons. Then she would look at me and say “Bo, go get my nurse” I would either press her big red button or I would just walk out of the room to find the nurse.

The point is defining “help” is challenging in a healthcare environment especially in a patient self-directed self-selection process. Evaluating “help” is even more challenging. There are numerous options and building the paddle would be a challenge. Ironically, in an industry move to be more efficient and direct patients needs to a caregiver using a decentralized design method – we lost a great deal of the data modeling. There is no way to track the request specifics in an automated fashion in a decentralized design without additional manual steps (which frankly defeats the purpose). There is no way to get specifics but there are request patterns.

There are ways to collect this request data – get a good understanding – then design you call processes. Just to take it a step further – we can tell you how many of each type of request hit when, how many were answered in your desired time frame (or what your average time frame), and even how the caregiver interacted with the request. If there is a hospital interested in knowing how to create a real patient centric care model – call us – we are looking for partners in a study to make life better.

The current analysis structure (at least what we have found published) looks at qualitative information – how many focus groups does it take to get to water, pain, and toilet? What’s crazy is all the information you could want to design the paddle or better the process is locked inside the nurse call system….if the hospital has a reporting package because most nurse call systems are built like archaic life safety tools with proprietary databases.

What’s more – I am the patient – I want to know how quickly you responded to my need – I know the information is there and frankly I know how to get to it. Stop and think how valuable that could be though - if I am going to do a survey (qualitative) to evaluate my care would it be better if I knew on average you answered my call light within 30 seconds every time PRIOR to me filling out the survey. Sometimes it feels like longer – but when you KNOW what the time is aren’t you more patient….Do you think that would influence my decision on whether or not I had good care?

But what do I know…. I am just a mom who had a sick baby and instead of blasting a hospital for a bad experience – I dug down to figure out how to solve for a pain I felt during a hospital stay.  It really is that simple….by the way so is the data.

"The Immediacy Conundrum"

Question #4 “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” Answers: Never, Sometimes, Usually, Always, and I never pressed the call button.


“after you pressed the call button”

Patience is not in abundant supply at Gate’s BBQ. When you walk in the door they shout at you - “Hi May I help you?” you must know to yell back very quickly – there is no patience for Umm or questions – by either the counter staff or the patrons behind you. You must shout back – quickly with full confidence - “Yes, I want a burnt end sandwich, fries, and a Ice Tea.” The food arrives to the counter very quickly – you can watch the man through the cook window constantly chopping and slicing meat to serve – you know it will be good, hot, and fresh.

The Gates atmosphere creates an expectation for an immediate response to questions, there must be no hesitation. I have reviewed reams of data from nurse call systems and 4 years ago when we started – the average wait time before exit of the bed for a patient was about 1:13. Now we see a majority falling under the 30 second threshold. Are people getting more impatient? Maybe…

We live in a world where as soon as I want to be connected my expectation is to have connection. The problem with “after you pressed the call button” is many patients expectation is immediate. Geeky techy stuff – if you have a nurse call system older than 2 years and you are functioning in decentralized – there is a lag time. Depending on the specific system – it can be an “eternity” in terms of immediacy. This is not a reflection on caregivers, it may actually be a reflection on the implementation of technology. Yet, caregivers are under pressure. Just like Gates, the health system and government is creating an atmosphere around hospitals that require immediacy. By its ever- more acute care criteria for entry, there is an equal expectation for immediate response?

Let’s talk solutions to the immediacy conundrum. The Decentralized Nurse Call craze of a few years ago is beginning to subside as hospitals realize the limitations of moving the patient call to an individual who is mobile and has variable task responsibilities on the unit. Decentralizing or sending the “Normal” patient call to a wireless device does not solve for immediacy – it’s actually the most difficult methodology for nursing to utilize because there is no immediate feedback on volume of requests or the “queue”. Immediacy requires the “queue” to be low and the person answering the call to interact and disconnect quickly. Think Economics - Basic Supply and Demand Theory – if you have too many nurses and not enough calls then you are fine. However, what is generally the case at documentable specific periods of shifts, if you have too many calls and not enough staff then you are going to get low scores on question 4.

The trick is the patient has a need and since they are not in their home environment and have very little control of their surroundings – many “wants” become needs. Not to mention the variation in expectation. The patient requires an immediate interaction – not an immediate solution. This is a really important point – so don’t miss it – the patient needs an immediate interaction and a sense that their need has been identified and help is on the way. The second key to this is you must deliver on the promise. So, if you have pushed your button and someone has quickly told you “help is on the way” then help must really be on the way. The only way to manage that is to develop a methodology to alert the needed caregiver with a specific request – data rich. Then Mobilize AND Monitor their action towards delivery. What does this mean – the person interacting with the patients request should be air traffic control – they should be able to monitor the total quantity of requests and estimate a delivery time. If there is a change in delivery time – maybe the patient should even be notified…..

BBQ and Nurse Call

I have noticed that several of my blog posts involve food…diets…etc It’s a true statement that one of my vices is really good food – not pretentiously good food – just plain good food. My pallet is not well refined, but I know when something tastes good and when I am served well.



One of my favorite restaurants is Jack Stack BBQ. Disclaimer: I live in Kansas City and talking BBQ is similar to talking about religion. There are alliances to BBQ that span generations of families. So, to be fair let me list the other greats in the Kansas City: 1)Gates – where “HI MAY I HELP YOU” is shouted at you when you walk in the door, 2) Arthur Bryants - where sweat is integral to experiencing the meal, and 3) Oklahoma Joes - only loses points because of the name.


According to the Kansas City BBQ Society (http://www.kcbs.us/ ), Carolyn Wells Ph. B, tells me it is measured on Appearance, Taste, and Tenderness. To achieve success in competition you must have quality in 5 areas: cooking unit, meat, seasoning, fuel, and most elusive, expertise of the chef.


For those of us with the untrained tongue, the challenge with BBQ is all data to assess are qualitative judgment’s – meaning, based on how I feel at that very moment I have made a judgment call on its goodness. Don’t get me wrong - when you taste a crispy chopped burnt end sandwich with just the right amount of salt, spicy sauce, and for me Cole Slaw on top, you will know what heaven will be like and I challenge anyone to say it’s not good.


So, what does BBQ have to do with Nurse Call? I look at Question #4 “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” Answers: Never, Sometimes, Usually, Always, and I never pressed the call button. I think would I ever answer "Always"?

One of the most concerning aspects of healthcare is measuring qualitative – questions based on “feelings” without creating a reasonable expectation for delivery. For example, asking “Did Jack Stack taste good?” to a random selection of people. (I have heard you East Coast folks think you know BBQ.) My perception of good BBQ is different than a person who prefers Memphis “Dry” BBQ , a North Carolina Vinegar based BBQ, and Texas hunk of meat they call BBQ.


In the next few blog posts I plan to break down question #4 and dig through how we can really expect to build continuous improvement and value from a “feelings” based survey question. How hospitals can use data that is existing in their facility to create quantitative Inidications of Care or what we call IndiCares™.


Just to get you started:


“During your hospital stay” this is a variable length of time. A metric based on an inconsistent variable is not easily understood and does not lend itself to being fixed. The time frame “your hospital stay” could be 1 day, 2 days, 1 week, or in a rare situation 1 month. The variable also could be a “frequent flier” as my favorite Children’s hospital calls their recurrent patients vs a one time in five years visitor. Their time may be short and consistent or random and long. 

We have evaluated data from over 30,000 patient days and the interesting thing about the data it is until you break it down by specific consistent measures there are very few patterns.  You have to stop looking at the data as Spaghetti and create a waffle structure.


A parting thought - If the data is barcoded according to which patient submitted it – why not just look at their nurse call statistics after their stay in comparison to their responses? If you are a hospital and don't know how to do that - call me or email me - I will tell you how to get to your data.